New Patient Intake Form

New Patient Intake Form

Step 1 of 13

Dear New Patient,

Welcome, and thank you for choosing Dr. Celaya as one of your health care providers.

OUR CONSULTATION PROCESS:

STEP 1:

During your initial consultation, Dr. Celaya will review your health history and make recommendations for lab tests that are appropriate for your specific health issues.

STEP 2:

Once you have completed your lab tests, Dr. Celaya will explain the meaning of your test results to you in a follow-up consultation. He will create an individualized therapeutic program for you including diet changes, nutritional supplements, and exercise, lifestyle, and stress management advice.

STEP 3:

Subsequent consults are scheduled to monitor your progress. Dr. Celaya will also design an on-going wellness program to be reviewed and updated with our staff at no charge every six months. We invite you to contact us via email or phone should you have any questions during the course of your treatment.

We look forward to assisting you in achieving your current wellness goals, and to guiding you in maintaining wellness throughout your life.

You will automatically be enrolled in our newsletter to provide you free cutting-edge health information to support you on your health journey. If you wish to not receive the newsletter, feel free and unsubscribe.

If you have had lab work within the last year, we want to see it. In addition, if you have had lab work even before that which is pertinent to Dr. Celaya understanding your health issues, make sure you send that to us also. You can send multiple files at one time with this option.

Lab reports

Drop files here or

If you have had lab work within the last year, we want to see it. In addition, if you have had lab work even before that which is pertinent to Dr. Celaya understanding your health issues, make sure you send that to us also. You can send multiple files at one time with this option.

Lab reports

Drop files here or

If you have had lab work within the last year, we want to see it. In addition, if you have had lab work even before that which is pertinent to Dr. Celaya understanding your health issues, make sure you send that to us also. You can send multiple files at one time with this option.

For existing patients only. Brief 15-30 minute consult. This consult is designed for questions on diet, lifestyle and the supplement program. 1 lab test may be reviewed if time permits.

Office - Troubleshoot Consultation$150

For existing patients only. A quick 15-minute consultation to troubleshoot any issues with your functional medicine program. Labs are not reviewed in this type of appointment.

Office - Comprehensive Consult $200

For existing patients only. Functional medicine 60-minute consult. During the consult diet, lifestyle, supplement program, and 2-3 labs test may be reviewed during this time.

Office - Nutrition Follow Up Consultation$100

Nutrition follow-up consultation.

After Hours Consultation

New Patient Consult After Hours$399

This is an after hour appointment for new patients to see Dr. Justin. New patient 45-60 minute consultation. If no times are available online in the next 1-2 weeks, please email the office as other times are set aside.

Trouble Shoot Consult After Hours$150

This is an after hour appointment for existing patients that need to see the Doctor sooner. Existing patient 15-30 minute consultation. If no times are available online in the next 1-2 weeks, please email the office as other times may be set aside.

Initial here to confirm fee schedule*

Appointments

Follow-up consults may be scheduled in 15, 30, 45, or 60-minute blocks of time. We encourage you to book your appointments 4 weeks in advance. As a courtesy to you, our office will email you 3-7 days in advance to remind you of your appointment.

Lab Tests

The results of your lab test(s) will be sent to Dr. Celaya 2 to 4 weeks after mailing your specimens to the lab. Dr. Celaya will evaluate the results. After your evaluation, you will be contacted to schedule a follow-up appointment. Certain blood work can be billed to the patient's insurance, depending upon the type and your deductible. When insurance is not available, cash discount options can be used to purchase blood work. The patient is responsible for any lab work their insurance does not cover.

Cancellations

If you are unable to keep your scheduled appointment, you must notify our office a minimum of 48 hours before your scheduled time or you may be charged for that appointment. Dr. Celaya has patients waiting to be seen, and a missed appointment takes time away from someone else.

If The Doctor Is Running Late

You must be available for the entire time of the consult. The Doctor may be running late with his previous patient, you will be charged a missed consult fee equal to the value of the consult if you are not available.

Initial here to confirm cancellation policy*

Super-Bills

All receipts given at check out contain cpt codes and IC10 codes that can be submitted to your insurance company for reimbursement. The easiest way to do this is by calling the customer service number on the back of the insurance card to receive instructions regarding the submission of your claim.

The Doctor is not responsible for any insurance claims that are not reimbursed. If there are any changes to a super-bill that need to be made, it is the responsibility of the patient to find out from their insurance what needs to be amended. The office will make adjustments to the super-bill at $5 fee per receipt. Any in depth paperwork that requires that Doctor to fill out will be charged to the patient at the doctors hourly rate.

Initial here to confirm super-bill policy*

Returned Products

PRE-APPROVAL IS REQUIRED ON ALL RETURNS!

Supplements (unopened and non-refrigerated items) may be returned with a 15% restocking fee of the purchase price for store credit.

No supplement returns will be accepted after 30 days on all regularly stocked items. No supplement returns will be accepted after 30 days.

Special orders and refrigerated products are non-returnable.

Prepaid tests can be returned for credit within 1 month of purchase.

All ingredients for Dr. C's supplements can be found in the store as well. It's the patient's responsibility make sure there are no specific allergens in the supplements before they are shipped, the best time to address this is during the supplement program design. If products are sent and allergies are found after the fact, the above return policy applies.

Important Notes

Dr. Celaya is not a medical doctor; he does not service medical emergencies. If you have a medical emergency, you must contact your primary care physician or dial 911!

Please contact the office if you are not clear on any of our policies or procedures.

Dr. Celaya is not providing you Chiropractic treatment.

Dr. Celaya does not treat or diagnose any disease. Dr. Celaya's work is to help support physical and chemical stress imbalances, with the goal of promoting wellness.

Communication Outside of Scheduled Consultation

Many people now use email as a primary way to communicate with others. We appreciate that email can be a great way to ask a quick question or clarify something from your last visit or share with us how you are doing. Yes or no questions are best with email correspondence. Questions that don't involve a back on forth dialogue that can be answered in 1-2 sentences are also acceptable.

We have found through experience, however, that email is often not the best way to deal with more treatment-oriented questions and decisions such as questions regarding your medical issues, changes in your symptoms, or complex requests. Instead, in these cases please schedule an appointment so your doctor will have time set aside to directly hear and address your concerns. If there is not time available on the calendar for a troubleshoot consult, please email and call the office so we can find a time to squeeze you in.

If you have sent us an email and have not heard back from us after several days, please follow up with a phone call.

Dr. Celaya is not a medical doctor, for any medical emergencies please call 911. If you are in need of refills on prescription medication, please see the original prescribing physician.

Initial here to confirm communication and shipping policy*

Clinic Policies and Procedures.A full list of policies and procedures can be found at http://www.drcelaya.com/FAQ (click here). All policies are subject to change. Please refer back to the website to stay up to date on any policy changes.

This authorization may be revoked at any time when the following stipulations have been performed:

Patient has already made new financial agreement that has been signed and dated or card holder/patient has submitted to our office a written request to revoke the card usage (stop billing credit card in writing signed and dated).

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